1 Min In Clinical
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Record learning outcomes
After reading this feature, you should be able to:
- Understand the risk factors and major signs/symptoms of mouth cancer
- Recognise the role that pharmacy teams can play in aiding the early detection of oral cancers in the community
- Provide customers with treatment and management advice for everyday oral health issues.
According to the latest figures, over 8,000 people are diagnosed with mouth cancer each year in the UK — equating to around one in every 50 cancer cases.1,2
Figures compiled by the Oral Health Foundation show that the number of diagnosed cases of oral cancer in the UK has risen by 103 per cent over the past 20 years, with increases seen every consecutive year of the past decade.2,3
The soaring cases of mouth cancer highlight the critical need to raise awareness of this disease, says Dr Nigel Carter, chief executive of the Oral Health Foundation. “While many cancers are seeing a reduction in the number of people affected, mouth cancer is one of very few that is sadly going the other way.”
Established risk factors like smoking and excessive alcohol have been joined by emerging causes like the human papillomavirus (HPV). This has changed the profile of the disease quite considerably over recent years – and mouth cancer can now affect anybody, says Dr Carter.
Spotting the danger signs
“One of the biggest challenges we face regarding mouth cancer is how little educational support it receives from Government and public health bodies…we will be working with thousands of organisations to improve awareness of the disease so that more people are able to recognise the early warning signs,” he says.
As part of this national drive to improve mouth cancer detection and diagnosis, pharmacy teams can play an important role in picking up on potential danger signs. “Although dental professionals remain the front-line of oral healthcare provision, pharmacy teams can play a key supportive role in helping to spot signs and symptoms of potential mouth cancers in the community setting,” says Miranda Steeples, current president of the British Society of Dental Hygiene and Therapy, and a qualified dental hygienist and dental therapist working in general practice. “This role is particularly important given the number of people who are currently experiencing difficulty in accessing a NHS dentist.”
The fact that nine in 10 cases of mouth cancer are completely curable with surgery if diagnosed early enough highlights the importance of efforts to expedite timely detection.1
Spotting signs and symptoms
Oral cancers fall under the broader umbrella of head and neck cancers and may present in different ways and in different locations in the mouth. The most common places to be aware of are on the floor of the mouth, the lateral borders (sides) of the tongue and at the back of the mouth, “but that is not to say that lesions cannot be found anywhere else”, says Steeples.
Oral cancers can also appear on the junction of the hard and soft palate, the cheeks, the tonsils at the back of the throat, and even outside on the lips. “Ulcers that take longer than three weeks to heal, and white, red or pinky speckled patches that may or may not look like an ulcer, or appear similar to a blood blister, should all be monitored carefully,” advises Steeples. “Anything that is ‘new to you’ is what I tell my patients,” she adds.
Other signs and symptoms that may raise a red flag for potential oral cancer include unexplained loose teeth or sockets that fail to heal after extractions, numbness or unusual sensations affecting the lips or tongue, or pronounced changes in speech, such as a lisp.
“The unusual patches that can indicate oral cancers are not always painful but if any ulcer or mouth abnormality does not resolve within three weeks, then the customer needs to see a dentist, dental hygienist or dental therapist, all of whom can make an appropriate onwards referral if needed,” advises Steeples.
Recognising risk factors
Unsurprisingly, the two major risk factors for mouth cancer are tobacco and alcohol. Estimates suggest that around 25 per cent of cases of oral cancer in the UK are caused directly by smoking and 35 per cent are attributable to excess alcohol intake.4
“It is well known that those who use tobacco, either in cigarette form, or by chewing it or using a shisha pipe, are all at heightened risk of oral cancers and tooth loss,” says Miranda Steeples. “Excessive alcohol consumption, especially at the same time as tobacco, can lead to a 30-fold increased risk of mouth cancer.
“Some brief advice around reducing the amount and frequency of alcohol consumption, plus referral to alcohol counselling services, alongside a recommendation to seek smoking cessation advice, or at least signposting for when the individual is ready, can be useful,” she suggests.
Another increasingly important risk factor for mouth cancer is infection with HPV, specifically the HPV16 variant, which can cause malignant changes in the mouth and throat. The link between HPV and oral cancer is particularly strong for oropharyngeal tumours.
Other customers who may be at heightened risk of oral cancer include those with a family history in a close relative and people with a weakened immune system.
Age also plays an important part in overall disease aetiology and consequently around two-thirds of mouth cancers develop in adults over the age of 55 years.1 Cases in younger adults are less common and usually linked to HPV infection. Men are affected more frequently than women but this is thought to be related to increased alcohol consumption rather than a gender-specific effect.
Another important cohort of customers not to overlook are those who spend a large proportion of their time outside and may therefore be at increased risk for a cancer of the lip. “These are often people who ‘don’t sunbathe’ and so don’t perceive their daily dog walk or time in the garden as exposure to the sun,” explains Steeples.
“They could be recommended to purchase a sun block of at least SPF30 for their lips. Someone coming in for travel advice, for example, or who is buying sunscreen for the rest of their body, should be encouraged to protect their lips as well.”
Also worth considering for onward referral is any customer with a persistent sore throat, lumps in the neck, hoarse voice, difficulty swallowing, or a cough that won’t clear. These are warning signs of potential cancer of the throat or lungs and customers should be signposted to their GP.
Brush aside – some practical advice on cleaning teeth
Always go to bed with clean teeth – the production of saliva is reduced at night, which lowers its effectiveness in neutralising the acids produced by lingering plaque.
Many people do not know that traditional toothbrushing only cleans up to 60 per cent of the tooth’s surface – the inside, outside and biting surfaces. This creates a perfect breeding ground for harmful bacteria to develop between the teeth, where food and plaque accumulate. Over time, this can lead to gingivitis (gum disease) and eventually tooth loss.
Along with brushing the teeth, people should take time to clean the gaps between their teeth, using dental floss or tape for tight spaces or interdental brushes if the gaps are wider.
Gums are made of soft tissue. To brush effectively, clean along the line where the gum meets the teeth. Brushing with too much pressure (or with too firm a toothbrush) can damage the gums, causing them to recede and exposing the root surfaces. These are not protected by enamel and are much more sensitive to changes in temperature and tooth decay.
Tackling common oral health problems
A range of everyday oral health problems are commonly encountered in the pharmacy setting and teams can play an important role in both identifying these conditions and helping customers with treatment recommendations.
Some of the most common oral problems for which pharmacy teams may be approached for help include bleeding gums, sensitive teeth, toothache, bad breath, denture issues and dry mouth.
For most people, the first sign of gum disease is blood on the toothbrush or mixed in with the toothpaste after spitting. Prompt action to tackle the causes of bleeding gums can help prevent progression to more serious gum disease and potential tooth loss.
A good oral care routine which involves thorough and effective cleaning of all surfaces of the teeth will help to remove plaque build-up at the gum line – the key cause of bleeding gums.
Important advice for customers suffering with bleeding gums should therefore include brushing twice daily with a fluoride toothpaste (spitting, not rinsing, after brushing), ensuring the toothbrush, or toothbrush head, is changed regularly – every three months – and carrying out daily cleaning between the teeth with either floss or interdental brushes.
Common oral health conditions
Symptoms of sensitive teeth can range from a mild twinge to more severe discomfort that persists for several hours. For most people, the key trigger is contact with cold, but hot or acidic/sugary foods or liquids can also elicit pain in sensitive teeth. The sensitivity itself stems from exposure of the soft dentine inside the tooth due to causative factors such as toothbrush abrasion, dental erosion or gum disease.
Gums can also recede naturally with age and tooth whitening can lead to a temporary increase in sensitivity. Specially formulated toothpastes are available to treat sensitive teeth and, in addition to regular brushing, some of the paste can also be applied topically to the affected teeth at bedtime.
To help avoid problems with sensitive teeth, Miranda Steeples, current president of the British Society of Dental Hygiene and Therapy, advises that people, “don’t brush too hard and reduce frequency of consumption of acidic food and drinks”. Anyone suffering with toothache or loose teeth should be seen by a dental therapist or a dentist, she says.
In the meantime, pharmacy staff can recommend simple oral analgesics such as paracetamol or ibuprofen for pain and inflammation relief and encourage customers to continue with their usual teeth cleaning regimen.
Bad breath can be an early warning sign of gum disease but can also occur as a result of plaque build-up, consumption of strong-smelling food or drink, or a dry mouth.
Steps that customers can take to help combat bad breath include practising good oral hygiene, using a tongue scraper, trying an antibacterial mouthwash and chewing sugar-free gum to help stimulate saliva production. For customers with persistent bad breath, suggest an oral healthcare check to rule out tooth decay or gum disease.
For sufferers of dry mouth (xerostomia), ensuring adequate hydration is key. Classes of medication that can contribute to dry mouth include antihypertensives, antidepressants and diuretics. Other possible causes include salivary gland problems, mouth breathing and natural reduction in saliva production with ageing.
Xerostomia can also be a symptom of some medical conditions including diabetes, Sjogren’s syndrome and lupus. OTC products available to help keep the mouth moist include lozenges, gels and sprays.
In cases where dry mouth proves particularly problematic, dental teams can recommend salivary substitutes to soothe the mouth, make chewing and swallowing easier, and improve taste function. Customers prone to dry mouth should also be advised to reduce their sugar intake and ensure they are using a fluoride toothpaste of at least 1450ppm twice daily.
For customers who wear dentures, daily cleaning of both the dentures and any remaining teeth is vital. To help boost confidence when eating, or if the appliance is prone to moving around, fixatives can be recommended. These are easily removed from the denture after use by brushing with soap and water. Dentures that are sore, rubbing, slipping or clicking may need to be adjusted, so customers should be advised to see their dentist or dental technician.
Smoking is an exacerbatory factor in almost all oral health issues – so advice on smoking cessation is important for any customer who has not yet quit.
Teachers providing toothpaste and brushes
The cost of living crisis is impacting on the oral health of children in classrooms across Britain, with most teachers now stepping in to provide pupils with the basics, according to research carried out by hygiene poverty charity Beauty Banks in partnership with the British Dental Association.
In a survey of secondary school teachers, four in five (83 per cent) said they or their school have given students toothbrushes and toothpaste. Eighty-one per cent said there were children in their school who didn't have regular access to toothpaste.
Toothpaste is now our most requested item – before the cost of living crisis, it wasn’t even in the top three, says Beauty Banks co-founder Jo Jones. NHS dental statistics show that just 44.8 per cent of children attended a dentist appointment in the past year, down from 58.7 per cent in 2019/20.
References
1. National Health Service (NHS).
2. Oral Health Foundation. State of Mouth Cancer UK Report 2022.
3. UK mouth cancer cases reach record high | Oral Health Foundation
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In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.